Provider Demographics
NPI:1063610749
Name:WEAVER, FRED C (OTC)
Entity type:Individual
Prefix:MR
First Name:FRED
Middle Name:C
Last Name:WEAVER
Suffix:
Gender:M
Credentials:OTC
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:304 S PARK LN
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALTUS
Mailing Address - State:OK
Mailing Address - Zip Code:73521-5718
Mailing Address - Country:US
Mailing Address - Phone:580-477-7356
Mailing Address - Fax:580-482-7510
Practice Address - Street 1:304 S PARK LN
Practice Address - Street 2:SUITE A
Practice Address - City:ALTUS
Practice Address - State:OK
Practice Address - Zip Code:73521-5718
Practice Address - Country:US
Practice Address - Phone:580-477-7356
Practice Address - Fax:580-482-7510
Is Sole Proprietor?:No
Enumeration Date:2007-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK87-0658246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist